As people approach and reach the end of life they, their families and carers are required to navigate increasingly complicated care systems to address their needs.
Current patient journeys are often poorly coordinated and this is particularly true for people with advanced chronic disease who have multiple comorbidities and a much slower and more unpredictable trajectory of functional decline (ACI, 2015)[1]. The needs of people, their families and carers during their end of life journey vary over time and care setting, meaning services need to be responsive, coordinated and flexible in meeting these changing needs.
It has been demonstrated that navigation support and or care coordination improves clinical outcomes and the experience and satisfaction of patients, families and carers.
A strong collaborative approach to care has been shown to not only increase patient satisfaction, patient care quality and optimise the use of finite resources, but is also likely to reduce errors, limit gaps in care and lessen unnecessary treatments and hospitalisations (NSW Health, 2019[2]; Palliative Care Australia, 2018[3]).
Provision of safe healthcare requires a synergistic approach with an emphasis on shared case management, effective communication, data sharing and teamwork between multidisciplinary professionals across all healthcare settings. A lack of continuous collaborative care is a contributing factor in adverse patient events (NSQHS, 2017)[4].
The Agency for Clinical Innovation conducted a review of the tools and resources supporting this component in 2021. The review identified local, national and international tools and resources that could be used to support the implement this essential component. None are specifically recommended or advised to be used in preference over another.
Click the Acknowledgement button below to view the working group members involved in the latest review.
Name | Role/Organisation |
---|---|
Dr Stephen Ginsborg |
General Practitioner, Northern Beaches; Board member, Sydney North PHN, Council on the Ageing (COTA NSW), Community Care Northern Beaches, & Manly Warringah Division of GP Working Group Co-Lead |
A/Prof Joel Rhee |
Associate Professor of General Practice, University of Wollongong; General Practitioner, HammondCare Centre for Positive Ageing+Care; Chair, RACGP National Faculty of Specific Interests - Cancer and Palliative Care Network Working Group Co-Lead |
Tamara Hollman |
Clinical Nurse Consultant Palliative Care, Western NSW LHD |
Jennifer Kasule |
Registered Nurse, Sydney LHD |
Renee Millen |
Paramedic Educator for Palliative Care, Ambulance NSW |
Kerrie Noonan |
Clinical Psychologist & Social Researcher, Macquarie Health Collective |
Hema Petal |
Primary Care Advancement Coordinator, Sydney North Health Network |
Victor Rocha |
Improvement Facilitator, Palliative Care Outcomes Collaboration (PCOC) |
Helen Smith |
Nurse Practitioner, Silverchain Western Sydney LHD |
Exploratory analysis of barriers to palliative care: Literature review
An Australian Government Department of Health commissioned literature review (2019) exploring the barriers and enablers of access to palliative care.
Rhee JJ, Grant M, Senior H, et al. Facilitators and barriers to general practitioner and general practice nurse participation in end-of-life care: systematic review, BMJ Supportive & Palliative Care Published Online First: 19 June 2020. doi: 10.1136/bmjspcare-2019-002109
The Groundswell Project works with individuals, organisations and communities to improve how people in Australia die, care and grieve.
National rapid discharge guidance for patients who wish to die at home
The aim of the Rapid Discharge Guidance is to facilitate a safe, smooth and seamless transition of care from hospital to community for dying patients who wish to die at home rather than in a hospital or hospice. Last revised in December 2019.
PalliAGEDgp and PalliAGEDnurse
The palliAGED apps provide nurses and GPs with easy and convenient access to information to help them care for people approaching the end of their life. Timely access to palliative care information can support the clinical care being provided. An online-offline capacity means they can use the apps anywhere in Australia. As the app is web-based, it can be updated as new evidence and resources are released.
Palliative Care Outcomes Collaboration (PCOC)
The PCOC program is a framework and protocol for routine clinical assessment and response to palliative care. The program helps in identifying and responding to patient needs generating consistent information to plan and delivery care.
The Advance ProjectTM – supportive care assessment + referral triage tool
The Advance ProjectTM is a practical, evidence-based toolkit and a training package, specifically designed to support Australian general practices to implement a team-based approach to initiating advance care planning (ACP) and palliative care into everyday clinical practice.
Using Resuscitation Plans in End of Life Decisions
NSW Health policy directive prescribes the standards and principles of care for appropriate use of Resuscitation Plans by NSW Public Health Organisations for patients in hospital for 29 days and over. A Resuscitation Plan is a medically authorised order to use or withhold resuscitation measures and which documents other aspects of treatment relevant at end of life.
Family meetings in palliative care: multidisciplinary clinical practice guidelines
Guidelines for health professionals working with cancer and palliative care patients developed by the Centre for Palliative Care Education and Research in 2009.
Multidisciplinary Case Conferences
Commonwealth Government specifications for MBS payments for multidisciplinary case conferences.
Multidisciplinary meetings for cancer care: A guide for health service providers
National Breast Cancer Centre produced guide (2005) for health service providers and multidisciplinary team members with ideas and tools to improve multidisciplinary care at a local level.
Core Palliative Care Medicines List for NSW Community Pharmacy
State-specific core medicine list for NSW community pharmacy developed by NSW Health.
Based on the ANZSPM core medicines list.
Prescribing S8 Medications in NSW
Any injectables, or hydromorphone for 2 months or more requires a written authority from NSW Health.
Australian & New Zealand Society of Palliative Medicine Palliative Care (ANZSPM) core palliative medicines list.
Care coordination of patients in RACF with palliative care needs
palliAGED developed resource for care coordination (last updated 2017).
This guide (2013) serves to provide GPs, general practice staff and RACF staff with advice regarding best practice for collaborative arrangements for the care of older persons (‘residents’) in RACFs in Australia, and has been designed to be read in conjunction with the RACGP (silver book) Medical care of older persons in residential aged care facilities.
RACGP Silver Book - palliative care approach
Medical care of older persons in residential aged care facilities, a Royal Australian College of General Practitioners (RACGP) publication commonly known as the Silver Book. Last revised in 2020.
Cancer care coordination (head and neck cancers)
A description of the service provided by the multidisciplinary team who work with these patients and their families.
Paula MacLeod Head, Neck and Thyroid Cancer Nurse Coordinator, Northern Sydney Cancer Centre, Royal North Shore Hospital